4 back in the day After discovery of insulin various purifications and sources were used to make it easier to produce and administer Modifications were made to extend its activity Recombinant production of human insulin lessened some of the immunological effects Still insulin therapy was delayed until all other options were tried for T2DM Insulin initiation was bedtime NPH Development of insulin analogs resulted in various products with longer or shorter activity

22 Self Titration of Insulin - Outcomes - One of the first studies to evaluate the use of carbohydrate counting in patients with type 2 diabetes Using a simple algorithm to adjust mealtime insulin glulisine each week based on SMBG patterns was as effective as adjusting mealtime insulin using insulin-to-carb ratios Both approaches yielded a reduction of about 1.5% in HbA1c; no significant differences in mean HbA1c change or % patients achieving HbA1c goals Bergenstal RM et al Diabetes Care 2008;31:

23 Current ADA Recommendations Published annually by the American Diabetes Association (ADA) Treatment recommendations developed jointly with the European Association for the Study of Diabetes (EASD)

36 Recommendations for Insulinization Emphasize lifestyle intervention; minimize weight gain and PPG excursions Provide each patient with a written insulin protocol as a point of reference Allow patients to actively titrate their insulin dose Teach patients how to identify and appropriately manage hypoglycemia When initiating basal insulin, use 0.2 U/kg/day as the starting dose If not controlled after FPG target is reached or if the total dose is >0.5 U/kg, treat PPG excursions with mealtime insulin If A1C level not at target after 3 months of basal + bolus, add second injection Patients on basal/bolus insulin therapy should use paired glucose testing to fine-tune their treatment regimens Unger J. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2011:4 253 American Diabetes Association Diabetes Care 2015;38(Suppl. 1):S41 S48

37 Additional Recommendations Keep it simple! Discontinue sulfonylureas and meglitinides before starting insulin Test the patient s numeracy and understanding of the algorithm ( if your blood glucose is X, then how much [insulin] would you give yourself ) If possible calendarize the algorithm (calendar software is inexpensive and adds one more level of simplicity) Call the patient to see how things are going Consider the cost of your regimen (work with a pharmacist to estimate costs of regimen and co-pays)

The basal plus strategy Denis Raccah, MD, PhD Professor of Medicine University Hospital Sainte Marguerite Marseille FRANCE ADA/EASD guidelines recommend use of basal insulin as early as the second step

KENTUCKY DIABETES NETWORK, INC. Algorithms for Glycemic Management of Type 2 Diabetes The Diabetes Care Algorithms for Type 2 Diabetes included within this document are taken from the American Association

1 When and how to start insulin: strategies for success in type diabetes Treatment of type diabetes in 199: with each step treatment gets more complex Bruce H.R. Wolffenbuttel, MD PhD Professor of Endocrinology

Workshop A Tara Kadis Considerations/barriers in decision making about insulin verses GLP-1 use in people with type 2 diabetes Which Insulin regimes should we consider? Diabetes is a progressive multi-system

Insulin: Breaking Barriers Enhancing Therapies Jerry Meece, RPh, FACA, CDE jmeece12@cooke.net Questions To Address Who are candidates for insulin? When do we start insulin? How do the different types of

Diabetes Mellitus 1 Chapter 43. Diabetes Mellitus, Self-Assessment Questions 1. A 46-year-old man presents for his annual physical. He states that he has been going to the bathroom more frequently than

Session 5: Insulin: Tried and True - Update on Best Practices in Clinical Use and Patient Adherence Learning Objectives 1. Design strategies to help patients overcome cultural barriers to using insulin,

Insulin Therapy In Type 2 DM Michael Fischer, M.D., M.S. Sources of support NaRCAD is supported by a grant from the Agency for Healthcare Research and Quality My current research projects are funded by

Diagnosis Patient MUST BE educated using carbohydrate counting for prial insulin coverage before hospitalization to be eligible for this order set Nursing Metered Glucose (Single Select Section) Metered

Session 5: Insulin: Tried and True - Update on Best Practices in Clinical Use and Patient Adherence Learning Objectives 1. Design strategies to help patients overcome cultural barriers to using insulin,

Present and Future of Insulin Therapy: Research Rationale for New Insulins Current insulin analogues represent an important advance over human insulins, but clinically important limitations of these agents

Overview Harmony is the global Phase III clinical trial program for Tanzeum (albiglutide), a product developed by GSK for the treatment of type 2 diabetes. The comprehensive program comprised eight individual

of nurse A new insulin order form should be completed for subsequent changes to type of insulin and/or frequency of administration 1. Check times for point of care meter blood glucose testing. Pre-Breakfast

Diabetes Treatment in a New Era: When to Begin Insulin and How to deliver it. Objectives 1. Briefly review the evolution of insulin therapy. 2. Identify the types of insulin currently available for treatment

Combined Therapy with Insulin Plus Oral Agents Is there Any Advantage? Matthew C. Riddle, M.D. Professor of Medicine Oregon Health & Science University Portland, Oregon Is there Any Advantage in Combined

Clinical Solutions in Diabetes Care 2008 Insulin Adjustment Helen Cressey and Clare MacArthur Helen Gibson and Moira Digby Welcome! First, an introduction with a few facts Some research Some considerations

Guideline for members of the diabetes team and dietetic department for advising on insulin dose adjustment and teaching the skills of insulin dose adjustment to adults with type 1 or type 2 diabetes mellitus

Presented By: Dr. Nadira Husein I have no conflict of interest Disclosures I have received honoraria/educational grants from the following: Novo Nordisk, Eli Lilly, sanofi-aventis, Novartis, Astra Zeneca,

Glycaemic Control in Adults with Type 1 Diabetes Aim(s) and objective(s) This document aims to provide guidance on good clinical practice in managing glycaemic control in adult patients with Type 1 Diabetes

INSULIN AND INCRETIN THERAPIES: WHAT COMBINATIONS ARE RIGHT FOR YOUR PATIENT? MARTHA M. BRINSKO, MSN, ANP-BC CHARLOTTE COMMUNITY HEALTH CLINIC CHARLOTTE, NC Diagnosed and undiagnosed diabetes in the United

Starting patients on the V-Go Disposable Insulin Delivery Device A simple guide for your practice For adult patients with Type 2 diabetes on basal insulin who need to take the next step Identify appropriate

Intensifying Insulin In Type 2 Diabetes Eric L. Johnson, M.D. Associate Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences Assistant

Calculating Insulin Dose First, some basic things to know about insulin: Approximately 40-50% of the total daily insulin dose is to replace insulin overnight, when you are fasting and between meals. This

Insulin onset, peak and duration of action Insulin was first discovered in the early 190 s. Before then, diabetes could not be treated. Insulin was then taken from cow and pig pancreases, but nearly all

INSULIN INITIATION IN TYPE 2 DIABETES IN PRIMARY CARE We welcome feedback on this policy and the way it operates. We are interested to know of any possible or actual adverse impact that this policy/procedure

Insulin/Diabetes Calculations Dr. Aipoalani St Lukes Endocrinology Goals Describe various calculations for insulin dosing Understand importance of the total daily dose (TDD) of insulin Be able to calculate

at The Valley Hospital (TVH) for Nursing Students/Nursing Instructors 2012 Subject - Insulin Safety Background Insulin known to be high risk medication Can promote serious hypoglycemia if given incorrectly

Insulin initiation in type 2 diabetes: Experience and insights Joan Everett A diagnosis of type 2 diabetes can be devastating for the individual and their family. Furthermore, many people with diabetes

Desktop Guidelines for Insulin Adjustment Disclaimer and terms of use: This document and workshop (the Material ) has been prepared for informational and training purposes for employees of the Endocrinology

Strengthening the Pharmacist Skills in Managing Diabetes Practice Based Program 27 Contact Hours Presented by New York State Council of Health system Pharmacists October 18 19, 2013 St. John s University,

dates for your practice March, 2013. Vol 2, Issue 14 TLALELETSO Managing Complicated Diabetes Diabetes is increasingly common Managing diabetes and working as part of a multidisciplinary team is essential

INSULIN FOR GESTATIONAL and PREGESTATIONAL DIABETES There have been several changes in the management of diabetes during pregnancy, including the use of insulin analogs. The Sweet Success Guidelines, revised